Medicare Will Use Private Payor Prices to Set Payment Rates for Clinical Diagnostic Laboratory Tests Starting in 2018

Last week CMS released a final rule implementing Section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA), requiring laboratories performing clinical diagnostic laboratory tests to report the amounts paid by private insurers for laboratory tests. Medicare will use these private insurer rates to calculate Medicare payment rates for laboratory tests paid under the Clinical Laboratory Fee Schedule (CLFS) beginning January 1, 2018. The final rule includes provisions to ease administrative burdens for physician office laboratories and smaller independent laboratories. In response to public comments, CMS moved implementation of the new payment system from January 1, 2017 to January 1, 2018 to allow laboratories sufficient time to develop the information systems necessary to collect, review, and verify data before reporting applicable information to CMS. This will also allow time for CMS to perform independent validation and testing of the CMS system through which laboratories will report applicable information, and allow laboratories to perform end-to-end testing of their systems with CMS’ system.  

Source: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-06-17.html